Chief Complaint: “coughing” x 3 months

Subjective:

56 y/o obese female with PMHx of psoriasis, osteoarthritis and hyperlipidemia presents to the office with c/o dry, non-productive cough for 3 months, associated with watery eyes and itchy throat. Cough is triggered by drinking cold fluid, also when she is around perfume, dust, and chemicals. The severe and prolonged cough is also leading to a sensation of urging to urinate and occasionally interrupting her sleep patterns. Denies fever, chills, night sweats, weight change, chest pain/tightness/heartburn, SOB, DOE, wheezing.

Objectives:

Allergies: none

Current Medication:

Ibuprofen 600mg tablet, 1 tablet as needed, orally 3 times per day

Triamcinolone Acetonide 0.5% ointment 1 application to affected area externally twice a day to scalp.

Vitals:

BP 116/80, sitting position, left arm

HR 88bpm, RRR

RR 16 breaths per minute, regular

O2 96%, room air

T 98.5 oral

Ht 5ft 2.75 in    Wt 218lbs     BMI 38.87

Physical exam:

General: in no apparent distress, good hygiene, A/O x 3

HEENT: Head: NC/AT, erythematous scaly plaque on scalp.  Neck: supple, no lymphadenopathy. Eyes: no redness, PERLLA. Nose: no deviation, no nasal discharge, no inflammation. Throat: tonsils are normal, no exudates or redness. Ears: normal tympanic membrane

CV: RRR, normal S1 S2, no murmurs, clicks, gallops.

Resp: clear to auscultation bilaterally, no adventitious sounds.

GI: soft, BS present, no hepatosplenomegaly

Extremities: no edema/swelling, pulses 2+ b/l

MSK: no swelling/deformity

Neuro: CN II-XII grossly intact

Assessment:

56 y/o obese female with c/o dry cough x 3 months, especially triggered by fumes and cold drinks. Mostly consistent with cough variant asthma.

Differential Diagnosis:

Cough Variant Asthma

Allergy

Post nasal drips

Acute URI

Acute Bronchitis

Plan:

• Cough Variant asthma:

Start Albuterol sulfate HFA Aerosol Solution, 108 MCG/ACT, 2 puffs as needed.

Start Fexofenadine HCl Tablet, 180 mg, 1 tablet as needed, orally, once a day

• Psoriasis:

Refill Triamcinolone Acetonide Ointment, 0.5%, 1 application to affected area, externally, twice a day to scalp

• Osteoarthritis:

Follow up with orthopedics

• Obesity and hyperlipidemia:

Weight loss and diet counseling done. Exercise, increase as tolerated.